Exam Questions and 100%Correct Answers with
Rationales ||Graded A+
The nurse notes that the client often sighs and says in a
monotone voice, "I'm never going to get over this." When
encouraged to participate in care, the client says, "I don't
have the energy." The nurse believes these cues are
suggestive of which nursing diagnoses? Select all that
apply.
A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
,E. Self care deficit - ANSWER-A. Hopelessness
B. Powerlessness
Rationale: Rationale: A nursing diagnosis is a clinical
judgment about a response to an actual or potential health
problem. This client is manifesting symptoms of both
hopelessness and powerlessness. Although the client
does report symptoms compatible with fatigue, there is no
direct data is given that indicates the client has interrupted
sleep patterns (option 3), disturbed self esteem (option 4),
or self care deficit (option 5).
Which of the following descriptors is most appropriate to
use when stating the "problem" part of a nursing
diagnosis?
,A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours - ANSWER-B. Anxiety
Rationale: The problem part of a nursing diagnosis should
state the client's response to a life process, event, or
stressor. These are categorized as nursing diagnoses. The
incorrect options are cues the nurse would use to
formulate the nursing diagnostic statement.
Which desired outcome written by the nurse is correctly
written and measurable?
, A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each
day
D. The client will breathe better after resting for 10 minutes
- ANSWER-B. The client will lose 4 lbs. within next 2
weeks
Rationale: An outcome statement must describe the
observable client behavior that should occur in response
to the nursing interventions. It consists of a subject, action
verb, conditions under which the behavior is to be
performed, and the level at which the client will perform